St. Luke's-Roosevelt Hospital Center

Teresita Octavo-Aziz, RN and Jonathan S. Steinberg, MD
Teresita Octavo-Aziz, RN and Jonathan S. Steinberg, MD
St. Luke's-Roosevelt was formed in 1979 by a merger of St. Luke's Hospital (established in 1846) and The Roosevelt Hospital (established in 1871). Their Arrhythmia Service performs a wide variety of electrophysiology studies and services, including 24-hour ECGs, monitoring, tilt table studies, cardiac ablations, and implantable cardiovascular defibrillator and pacemaker insertions. See what makes this hospital s labs so successful. What is the size of your EP lab facility and the number of staff members? What is the mix of credentials at your lab? There are three rooms used for electrophysiology procedures at St. Luke s-Roosevelt Hospital Center. There are a total of 22 staff members of the Arrhythmia Service at St. Luke s-Roosevelt. This includes five attendings, two electrophysiology fellows, seven clinical nurses, two research nurses, one nurse practitioner, one physician s assistant, two technicians, and two secretaries. When was the EP lab started at your institution? The Arrhythmia Service and EP lab was established in January 1991 by Dr. Jonathan Steinberg, the current Arrhythmia Service Director. What types of procedures are performed at your facility? Approximately how many are performed each week? What complications do you find during these procedures? A great variety of procedures are performed in the EP laboratories, including ICD and pacemaker implantation, catheter ablation of all varieties of arrhythmias (atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, atrial flutter, etc.), comprehensive electrophysiologic studies, and biventricular pacemaker implants. There are also lead extractions, tilt table studies, cardioversions, etc. Each laboratory performs 18-20 procedures per week. Fortunately, complications are rare, but can include access site bleeding/hematoma, lead dislodgment, or cardiac tamponade. Is the EP lab separate from the Cath lab? How long has this been? Are employees cross-trained? The EP lab and Cardiac Catheterization lab function completely independent of each other there is a separate staff and leadership. However, nursing staff in the Cath and EP labs are cross-trained, but are rarely called on to cover for one another. How is your EP lab managed and by whom? The Arrhythmia Service is directed by Dr. Jonathan Steinberg, who is also the Division of Cardiology Chief. The EP lab is managed by Teresita Octavo-Aziz, RN. Do you have cross-training inside the EP lab? All nursing staff is credentialed in the full range of EP laboratory procedures. Nurses share responsibilities in preparing the room and procedure tray, setting up the patient, circulating, and administering conscious sedation, patient care and defibrillation. Electrophysiology equipment, such as recording, monitoring, and mapping systems, are typically manned by the EP attendings, fellows, and support staff. What are some of the new equipment, devices and products introduced at your lab lately? How has this changed the way you perform those procedures? A variety of sophisticated and innovative equipment and products have been introduced into the laboratory. Among the most dramatic and important have been CARTO, the electro-anatomic mapping system by Biosense Webster Inc. (Diamond Bar, California), and the catheter localization system, LocaLisa ® (Medtronic Inc., Minneapolis, Minnesota). Ablations are sometimes performed using 8-mm tip catheters, irrigated tip catheters, and cryocatheters. The mapping systems have greatly facilitated the identification of origins of complex arrhythmias. The different ablation systems have made ablation more effective, especially for deep and/or large arrhythmia circuits. For lead extractions, we use the Spectranetics CVX-300 system, which has greatly facilitated chronic lead extractions, including ICD and PPM leads. One of the most important advances has been the regular usage of an intracardiac ultrasound, the Acuson AcuNav system. This allows our physicians to perform transeptal catheter access and monitor for thrombus formation. The advent of biventricular pacing has greatly enhanced our ability to treat heart failure patients and is performed in increasingly large numbers of patients. Is your EP lab filmless, or does it plan to be in the near future? Since the most recent renovation, all of our EP laboratories use digital technology and are filmless. Who handles your procedure scheduling? Do you use any particular software? How do you handle physician timeliness? All procedures are scheduled through the EP nurse coordinator and/or the EP scheduler. Most of the outpatient and same-day admit patients are seen initially by the attending physicians in their office practices, and information is passed on to the EP nurse coordinator who then follows up directly with the patient. Communication with the patient includes scheduling and informing them about the nature of the procedure, as well as mailing instructions, sending a patient information booklet, etc. EP attendings are assigned specific time slots and are generally available to do all procedures scheduled for their slot. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Ordering supplies are coordinated by the EP nurse leader and her staff. Daily counts are performed to determine what supplies are needed over the next few weeks and then are ordered. Generally, the physician leaders determine what equipment and products are stocked in the lab. We are part of a large purchasing network, which to some degree controls what products are available in our lab. However, the physician leader, Dr. Steinberg, has a leading role in this decision making process, so by and large we have been able to continue to have the products that we deem critical and important. The reason that we have been able to obtain better pricing is by participating in this purchasing network. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? The EP lab volume has grown between 15-25% per year every year that our labs have been in existence. We continuously struggle to keep up with the volume that is referred to our laboratories. Fortunately, our hospital has supported us, and we have expanded the number of EP laboratories too. We are able to perform procedures in up to three laboratories on any given day. Two of the laboratories are fully dedicated to EP procedures and one is shared with the catheterization laboratory. We are in the process of planning the construction of three full-time EP labs. We anticipate continued growth, based on referral patterns as well as the nature of electrophysiology. We have already identified a sixth attending to join our group to accommodate this additional volume. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? The laboratory and group operate independently of other groups in the local community. Cases can be referred from physicians affiliated with our institution. In addition, our doctors receive referrals from all over the metropolitan area. Physicians refer for special procedures such as atrial fibrillation (AF) or pulmonary vein ablations from all over the Northeast, and even throughout the United States and Europe. What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies and patient throughput? We are trying to improve basic nursing coverage in the laboratory. We have instituted staggered scheduling for our nursing staff, so the lab is able to run longer hours without incurring expensive overtime costs. The EP staff is a highly dedicated and collaborative group. Everybody pitches in to move cases as quickly as possible through the lab. In turn, the lab is able to increase throughput. We pride ourselves in being able to limit the amount of time between cases; we try to do an extremely efficient job. The bottom line is that we place a premium on limiting the amount of time that the labs are inactive. Does your EP lab have an outpatient program? The Arrhythmia Service has two separate pacemaker clinics and one ICD clinic, three half-day slots a week. These are generally coordinated by our physician assistants and are also attended by an electrophysiology fellow and an Arrhythmia Service attending. Of course, all the attending physicians have outpatient practices through which many patients are initially seen and then referred for a variety of procedures, especially devices and catheter ablation procedures. Electrophysiology fellows also have their own clinic at which they receive referrals from other cardiology fellows as well as from other clinics and departments within the hospital. How are new employees oriented and trained at your facility? We have 12-14 weeks of EP orientation, an additional 1-week rotation in the cath lab, and 1 week in the holding room. All candidates are required to have a critical care and cardiology background before consideration for positions within our laboratory. What type of continuing education opportunities are provided to staff members? Nurses of the institution are permitted to attend three continuing medical education days throughout the year. The Arrhythmia Service at our institution also runs several high-quality educational conferences for physicians in the local community, which we regularly attend. The weekly EP conferences are also highly valuable and all nurses who are in the hospital at that time attend. Clinical cases are often reviewed, and there are also didactic conferences and journal club presentations. We also have in-service presentations given by pacemaker reps to introduce new equipment to our laboratory. How is staff competency evaluated? A combined competency checklist is required for all cath and EP lab nurses. At least two activities are formally assessed for each employee. In addition, there are hospital-wide nursing competencies that all our staff is required to be evaluated on. Have you had any interesting or bizarre cases come through your EP lab? We have had a large number of difficult referrals sent to our physician staff, who has seen a number of challenging cases. We have had several dextrocardias that required either ablation or device implantation. The atrial fibrillation and pulmonary vein ablations are almost always interesting, although they are more difficult procedures. Some of these cases have been plagued by atrial fibrillation for so long that their doctors had given up hope of restoring sinus rhythm. Then we ablated their atrial fibrillation focus, normal sinus rhythm was restored and patients have done dramatically well. How does your EP lab handle call time for staff members? The EP nurses do not have on-call, although all perform overtime duties. Unfortunately, our cath lab colleagues are not as lucky. What type of control/quality assurance measures are practiced in your EP lab? The EP laboratory has a weekly clinical conference. At this conference, when appropriate, we present cases for review by the entire team, including nursing staff. We find this extremely helpful to review our policies and procedures, and make changes as appropriate. Everyone gains from this process, and it is not considered harsh or punitive. Of course, we make appropriate reports to the institutional authorities. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? I would say that less than 10% of procedures are done with cryo. We use radiofrequency in about 90% of cases. Does your lab use a third party for reprocessing? No. Does your lab use provide surgical backup for procedures? We use surgical backup for some extraction procedures only. What trends do you see emerging in the practice of electrophysiology? Due to the aging of the general population, we are expecting a much greater number of cases in atrial fibrillation and congestive heart failure (CHF). Since we have been actively involved in the ablation of AF and biventricular pacing for CHF, we are attempting to ramp up our staff, physician, and laboratory capacity to be able to handle the expected bolus of cases. In particular, ablation of atrial fibrillation via pulmonary vein isolation has really overwhelmed our lab s capacity much more rapidly than we ever anticipated. We also anticipate a huge number of device implants, given recent clinical trial results. Our laboratories are designed for rapid ICD implants, and we are considering specific design changes so that the labs will be more efficient for device implantation as an additional way to handle new volume. Because of our laser lead extraction interest, this is also an area of future growth, as devices and leads have been implanted for a long time, especially leads that do not have the longevity of contemporary leads. We are seeing increasing numbers of patients who need to undergo this complex procedure. Does your EP lab undergo a JCAHO inspection? In addition to our usual quality control, our lab has a JCAHO inspection every three years. Does your EP lab provide any educational or support programs for patients who may have additional questions or for those who may be interested in support groups? From the initial contact by a nurse to a prospective patient, the patient is provided with information regarding the specific arrhythmia condition and/or procedure. This includes written materials, such as descriptive letters, pamphlets, videotapes, and instructions to visit our website. The website is highly informative and interactive, and patients are able to understand their condition and procedure via this process. We encourage patients to call us should more questions develop, and we also routinely do follow-up calls to ensure the patient is all set for prep and procedure. At discharge, written instructions and follow-up calls are made. When called after hospital discharge, we check on status and make sure follow-up instructions are clear. We also perform regular ICD support group meetings and have been since the initiation of that service many years ago. These are typically performed 2-4 times per year and we choose the subjects so that we have large attendance by our ICD group. Fortunately, we have generously received support to make this feasible. Give an example of a difficult problem or challenge that your lab faced. How was it addressed? It is always a challenge to convince the institution to make a large investment in expensive labs and equipment that are required for the Arrhythmia Service. Our physicians make detailed justifications and business plans that document the present and future needs of the Arrhythmia Service. We try to stay ahead of expected referrals and patterns of EP lab procedures. We also work closely with our finance department and billing staff to make sure that we are knowledgeable about the appropriate reimbursement practices and coding procedures. This is a highly challenging and difficult task. Is your EP lab currently involved in any clinical trials or special projects? The Arrhythmia Service has always been, and is currently actively involved, in a variety of clinical research projects; some of these initiated by our own staff and institution, and others are from multicenter clinical trials. We have always had immense commitment from our local physicians, referring physicians, and Arrhythmia Service staff, who have typically been active in enrollment. For example, recent studies include AFFIRM, MADIT II, DAVID, SCD-HeFT, ablation studies, coagulation abnormalities in atrial flutter, biventricular pacing, and a RV dysplasia registry. Please tell our readers what you consider unique or innovative about your EP lab and staff. I think the greatest strength of our EP laboratories would be the cooperative spirit of our staff and our physicians. Our nursing staff works very closely with one another, covering each other, learning from each other, working closely with our physicians, and being very dedicated to the welfare of our patients. We try to be more knowledgeable about electrophysiology and its procedures to make sure our patients are comfortable. Our physicians extensively use the nursing staff to educate the patients and ensure that pre- and post-procedure communication is optimal. We have always enjoyed a close working relationship with nurses and physicians and consider ourselves lucky. For more information, please go to their website: www.Arrhythmia.org